Fill and Sign the Krs Chapter 202a Hospitalization of the Mentally Ill Form

KENTUCKY ADVANCE DIRECTIVE FOR MENTAL HEALTH TREATMENT (K.R.S. 202A.422) I, _____________________________, willfully and voluntarily execute this advance directive for mental health treatment. I want the instructions in this advance directive to be followed as described below. Designated surrogate: I am naming a surrogate to see that my instructions for mental health treatment are carried out. I am not naming a surrogate to see that my instructions for mental health treatment are carried out. I designate _____________________________ to act as my surrogate. If this person withdraws or is unwilling to act on my behalf, or if I revoke that person's authority to act as my surrogate, I designate _____________________________ to act as my alternate surrogate. If I do not designate a surrogate, if my surrogate and alternate surrogate withdraw or are unwilling to act on my behalf, or if I revoke their authority to act, then the health care provider and health care facility may proceed to render treatment in accordance with my instructions as described here and in accordance with standards for mental and physical health care. The person acting as my surrogate is authorized to act in accordance with the content of this advance directive and may override the advance directive if, and only if, there is substantial medical evidence that failing to do so would result in harm to me. If my instructions and preferences are not stated in the advance directive, the surrogate may act in good faith in making treatment decisions in the manner in which the surrogate believes I would act. Psychotropic medication provisions: I may indicate below any refusals of treatment with specific psychotropic medications, not to include an entire class of medications, due to factors that may include but are not limited to lack of efficacy, known drug sensitivity, or experience of adverse reaction: I specifically do not consent and do not authorize my surrogate to consent to the administration of the following medications or their respective brand-name or generic equivalents for the reasons given: Specific psychotropic medication: _____________________________
  a. (c) a surrogate may not administer a specific psychotropic medication or its respective brand-name or generic equivalent to me when it is known or reasonably suspected that: (1) I have a psychiatric disorder; or (2) i may experience a psychiatric episode due to the medication. B. (d) the medical treatment in my mental health care facility has already been rendered because the medications used were the same or similar to those which the health care provider has already prescribed for me under my advance directive. C. An alternative health care provider may render the medical treatment in my mental health care facility provided that: (1) the medical treatment in my mental health care facility has already been rendered because the medications used were the same or similar to those which the alternative health care provider has already prescribed for me under my advance directive. (2) the alternative health care provider or the individual who administers the alternative health care facility shall comply with all relevant sections of this directive. (e) a medical treatment is deemed rendered to me if the individual who provided the medical treatment shall have fulfilled: (1) the medical treatment in my mental health care facility; and (2) any other medical requirements pertaining to that medical treatment that are set forth in this advance directive. D. (f) a statement in a person's advance directive that medical treatment has been rendered under the circumstances set forth in paragraph (d) of this section does not supersede the limitations set forth in other sections of this advance directive to the extent necessary to prevent an emergency situation on the part of the person or where those limitations conflict with the person's desire to proceed with medical treatment. E. When a statement in a person's advance directive is found later to be inaccurate, the statement shall be corrected on such terms that: (1) the person cannot be forced to sign such a statement; or (2) the statement does not conflict with the person's desires, including, for example, where the person requires medication for.